A detailed overview of Endometriosis

What is Endometriosis?

In the normal development and functioning of the female reproductive organ, the endometrium plays a key role in menstruation as well as in pregnancy. The endometrial lining is a lining or a ‘wallpaper’ made up of tissues that layer the uterus and shed as the menstrual period every month.

Endometriosis is a painful and uncomfortable disorder in which the endometrial tissue grows outside the uterine cavity. It can be found on the fallopian tubes, ovaries, on the intestines among other places. This causes irritation in the surrounding tissues and results in scar tissue formation or abnormal bands of fibrous tissue in the pelvis. Endometriosis can result in severe pain, especially during menstruation, and can also cause infertility problems.

What are the signs and symptoms of Endometriosis?

The tissues of endometriosis are similar to the endometrial lining – it forms, thickens, and sheds much like the endometrium, in the form of menstruation. But since it is developed outside the uterus, there is no way for the tissues to exit the body. This causes severe pelvic pain especially around the time of menstruation.

The following are some signs and symptoms of endometriosis:

  • Heavy, long, and painful period
  • Severe lower back pains and cramps
  • Pain and bleeding during excretion
  • Infertility
  • Pain during intercourse
  • Bleeding in between periods

Other signs of endometriosis include diarrhea, constipation, nausea, and fatigue. Severe migraines and allergic reactions worsening during menstruation are also some uncommon symptoms of endometriosis.

Does endometriosis affect fertility?

While endometriosis doesn’t directly affect fertility, women with endometriosis do run a significantly low chance of getting pregnant. According to the American Society of Reproductive Medicine, up to 50% of women who suffer from infertility have endometriosis, and women who have endometriosis typically suffer from infertility in 30 – 50% of the cases.

The following are some ways and signs of endometriosis infertility:

  • Scarred fallopian tubes
  • Impaired implantation of the embryo
  • Adhesions binding the pelvis and organs
  • Hormonal changes in the egg
  • Inflammation of pelvic organs
  • Distorted anatomy of the woman’s pelvis

The inflammation caused by endometriosis produces inhospitable molecules (cytokines) that hinder the process of fertilization. Furthermore, large endometriosis cysts in the ovaries, adhesions, and scar tissues in the uterus and fallopian tubes, restrict the sperm and the egg from coming in contact with each other. These inflammatory molecules can also cause permanent damage to the ovarian reserve at a molecular level as reflected by reduced ovarian reserve AMH tests. Sometimes, the condition also hinders ovulation, causing the eggs to get trapped within the ovaries. All these collective issues may cause infertility or may result in high-risk pregnancies and miscarriage.

Treatment of endometriosis infertility:

Unfortunately, there is no cure for the signs and symptoms of endometriosis. The condition can, however, be controlled through pain medications, hormonal contraceptives, and progestogens. In some cases, conservative surgery is also suggested for women who want to get pregnant and/or suffer from extreme pains.

1. Pain medications: Over-the-counter painkillers like ibuprofen and paracetamol can be used for endometriosis pain, although this is not a long term solution to the discomfort.

2. Hormonal contraceptives: Hormonal medications and treatment are prescribed as it helps reduce the severity of the lesions. These medications help in reducing the pain, ectopic endometriotic tissues, and even the lesions to some extent and allow the lesions to recover. Some hormonal medications for endometriosis include:

  • Combined Oral Contraceptives (Coc)
  • Progestogens, including contraceptive injections and implants
  • Gonadotropin-releasing hormone (GnRH)
  • Aromatase inhibitors

It is to be noted that hormone treatments reduce your chances of fertility but do not permanently affect fertility and can be used to control the effects of endometriosis.

3. Surgery: In some cases, doctors may suggest severe endometriosis surgery to get rid of endometrial growth or to remove the ovaries on the whole. Over the last decades, surgery has been classically used to both diagnose endometriosis and simultaneously treat the lesions, which helps in decreasing the pain and improving the patient’s quality of life. Traditionally, surgery was done through laparotomy, which means opening the abdomen and removing the lesion. Compared to conventional laparotomy, the laparoscopic excision of endometriotic ovarian cysts is associated with less blood loss, lower complication rates, and shorter hospital stay. The severe endometriosis surgery approach is associated with some benefits such as pain relief, prevention of cyst rupture, long-term risk of malignancy, etc. the role of the surgical approach in endometriosis is still a matter of debate as it might account for ovarian damage, leading to decreased ovarian reserve and worsening infertility.

Different types of approaches like cystectomy (removing the ovarian endometriosis cyst), energy ablation (which uses lasers or thermal energy to destroy the deposited lesions), or a combination of both can be used depending on the extent of the disease. But studies suggest that surgery should be reserved nowadays just in those cases of refractory pain to medicines, sonographic signs of malignancy, the rapid growth of the cyst or inaccessible follicles for oocyte retrieval, regardless of endometrioma size.

Endometriosis and IVF:

Many women resort to in vitro fertilization after being unable to conceive with endometriosis. If the size of the endometrioma is too large that it may cause problems during ovum pick-up, endometriosis surgery may be suggested to get rid of the endometrial growth, before starting the IVF process. Although it may be difficult to conceive with endometriosis, studies show that 7 out of 10 with mild to moderate endometriosis are still able to get pregnant without any or with minimal medication.

For women who are infertile and wish to get pregnant, the best approach is to opt for IVF at the earliest as the endometriosis causes ovarian damage and might worsen the already affected ovaries. Numerous studies have shown favorable results in young women with endometriosis and IVF.

Fertility Preservation – the most important thing to do:

It is quite evident by large studies that endometriosis – the disease itself and its severe endometriosis surgery, cause permanent ovarian damage due to various chemical mediators, compression of the ovary by the expanding lesion or by performing surgery as some normal ovarian tissue is unintentionally removed during the procedure. This is shown by the reduced AMH levels in these women. Thus it is very essential to obtain eggs at the earliest to get a good number and quality of embryos for future use. For young or unmarried women, oocyte cryopreservation is considered the gold standard, while women with a stable partner can also opt for embryo freezing.

Endometriosis is a painful condition but can definitely be dealt with to quite an extent. With the right medications and required procedures, it will no longer pose a threat or hurdle in your day to day life. If you or anyone you know suffers from the condition, consult a doctor immediately, or book an appointment with Dr. Banker today. 

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